CLM-2026-014687
Evergreen Diagnostic Imaging, Radiology. Service 2026-03-11 at outpatient hospital (POS 22). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Joyce Griffin
- Member ID
- UHC-02702-65
- Date of birth
- 1968-07-25
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-406145
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8311
- Coverage period
- 2022-05-01 to present
- Deductible
- $1,647.71 of $2,500.0066%
- Out-of-pocket maximum
- $1,790.07 of $7,500.0024%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- PA2026147556 / REF701311
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $157.00 | $86.35 | $86.35 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $2,787.00 | $1,532.85 | $842.63 | $690.22 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,879.00 | $1,033.45 | $103.35 | $930.10 | Paid |
| Totals | $4,823.00 | $2,652.65 | $1,032.33 | $1,620.32 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-738474
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023997 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-11: CORE-HMO (HMO), effective 2022-05-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026147556 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (4970897466). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Diagnostic Imaging2026-03-11 09:40
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026147556_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-03-11 to 2026-06-09.
- Itemized billitemized_PA-738474.pdf2 pages
Itemised statement totalling $4823.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015515 | 2026-07-29 | Lakeside Physical Therapy | $447.00 | Approved |
| CLM-2026-007882 | 2026-03-31 | Desert Medical Group | $360.00 | Needs review |
| CLM-2026-007881 | 2026-03-31 | Desert Medical Group | $360.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.